Factors Influencing Communication Between the Patients with Cancer and their Nurses in Oncology Wards

INTRODUCTION

Relationship with the patient is the major component of nursing care. In fact, along with other organizational factors, it would help to build a positive relationship between nurse and patient. Furthermore, it helps in providing quality nursing care. Researches on nursing care often complain about poor relationship,[12345] and patients often feel health care personnel do not meet all their communicative needs. According to the Research Center for Quality Care, 10.8% of patients believe that caregivers sometimes or never listened to them carefully, do not explain things clearly, they do not respect what patients say, and do not spend enough time with them.[6] Because of asking questions or expressing their concerns, some patients have to face with inappropriate behavioral reactions of caregivers. Gaps in communication between caregivers and patients result in decreased quality of care, poor outcomes, and dissatisfaction with health care system.[7]

Nurses play a major role in cancer care, because cancer nursing not only focuses on the biological and medical aspects of care, but also on the emotional aspects. Therefore, such care requires a comprehensive understanding of the patient.[8] As cancer care is affected by factors related to the patient and organizational factors,[9] this leads to many communicative problems experienced by nurses that consequently leads to excluding patients from sharing their concerns with them.[10] In other words, the roles of patients and caregivers in influencing communication processes are equally important.[11] Moreover, factors such as the competence of nurses in communication skills, training programs to improve the nurse-patient relationship, task-oriented view, insufficient skills in providing psychological aspects of care for patients who are living in difficult emotional situations, seeking information by patients and having a role in caring themselves and that they do not want to talk about the disease and their feelings in such cases have been mentioned.[12]

Studies show that nurses often fear from situations when patients express emotions that they are unable to manage. Therefore, through changing discussions, they prevent patients from expressing their concerns. In most cases, the emotional issues are not being selected as the main topic; instead, they tend to provide information and practical care. In fact, these barriers lead to inadequate emotional support for patients.[51213] Fakhr-Movahedi et al. studied the nurse - patient relationship in Iran and showed that factors such as organizational factors, culture and tradition, expectations from nurses, and heavy workloads can limit the time allocated to communicate with patients and reduce the effectiveness of communication.[4]

In addition, although nurses’ communication behavior, including friendly personality, kindness, quick response, and timely attending to the needs of patients, allocating sufficient time to provide care could improve communication with the patient, heavy workload and shortage of nurses, are common problems that are prevalent in the training hospitals of Iran, which could potentially affect this behavior.[14] On one hand, it should be noted that facilities for palliative care in cancer in Iran are currently limited to only a few centers in major cities, and as a result, referring patients with a variety of needs and concerns increases the workload in oncology units.[15] On the other hand, the number of nurses in the country has not reached the standard that it can influence the quality of nursing care and effectiveness of communication with patients.[16] Cancer care system is based on the biomedical model and the unwillingness to allocate authority to the patient for clinical decision making affects the patients, share in nursing care. Moreover, increasing level of education, patient's expectations, and more familiarity with his/her rights causes the patients to demand more authority and effectiveness in their communications with the caregivers. Communication gap is one of the reasons for the dissatisfaction of patients in the country.[17]

To improve health care and reduce patients’ dissatisfaction, the factors that affect communication between nurses and patients must be identified and taken into account, also response to all communication needs of patients should be provided.[18] Therefore, this study was conducted with the aim of exploring the factors influencing the communication between cancer patients and their nurses.

MATERIALS AND METHODS

In this study, in order to explore participants’ experiences of factors influencing communication, qualitative content analysis approach was used. Participants (nine patients, three family members, and five nurses) were chosen based on purposive sampling and saturation principles using the following inclusion criteria for patients: 1) They should be at least 20 years old, and 2) they should not be suffering from mental disorders according to their records. The inclusion criteria for family members were: 1) They should be at least 20 years old, and 2) they should have experience of accompanying patient during hospitalization; the criteria for nurses were: 1) At least one year of nursing experience in oncology unit, and 2) a minimum of a bachelor's degree in nursing. This study was conducted in two main oncology centers in Tabriz that include Ali-Nasab Hospital and Shahid Ayatollah Qazi Tabatabaee hospital.

The data were collected during the months of May to December 2012 using semi-structured and in-depth individual interviews. All interviews were audiotape-recorded. In-depth individual interviews were performed in an isolated room for the participants’ comfort. The interviews that lasted between one and two hours started with general questions but progressively, questions became more detailed pertinent to the study. For example, “What experience do you have in communication with cancer patients? What are your experiences of nurses’ communication with you? How nurses act for you?” In case of need, the researcher, with follow-up questions, asked participants to express experiences, memories, and more description of their understandings of what they say. Natural behaviors and patient-nurse interactions were observed in the environment, and field notes were prepared in the same environment as well. It means that notes recorded interaction of nurses with patients during nursing care, chemotherapy, or bone marrow biopsy.

The researcher transcribed the interviews and field notes verbatim and read them all several times to obtain full understanding of the data. Whole interviews and field notes were contemplated as units of analysis. Words, sentences, and paragraphs considered as the meaning units were condensed according to their content and context. The condensed meaning units were abstracted and labeled with codes. Codes were sorted into subcategories and categories based on comparisons regarding their similarities and differences. Finally, a theme was formulated as the expression of the latent content of the text.[19]

The Research Council and Ethics Committee affiliated to Kerman University of Medical Sciences approved the study proposal (with No K.91.125). The aims of the study were explained in detail to the participants. The following information was given to the participants: The voluntary nature of the participation, their right to privacy, anonymity, and confidentiality as well as right to withdraw from the study at any time without any penalty. The participants then signed an informed consent form. During observation sessions, informed consent was obtained dynamically and continuously from both nurse and patient.

To increase the validity of the data, the codes were compared, and the differences were discussed and re-evaluated in group research, until shared codes and categories were created. In addition, parts of two interviews that converted to text had been sent to two expert researchers in the qualitative research on cancer. The agreement between the external coders with codes of researchers was measured using Holsti method,[20] which was an average of 78%.

RESULTS

All the nurses participating in the study had a bachelor degree, and their work experiences in oncology unit ranged from a year and half to 29 years. There was just one male. Two of them were head nurses. The patients’ age ranged between 20 and 59 years, and there were three females. The patients were diagnosed with and were being treated for leukemia, breast cancer, colon, lymphoma, sarcoma, stomach, and liver cancer.

Data analysis resulted in the emergence of the “three-factor effects” theme. This theme suggests that despite the desire of nurses and patients to establish a patient-centered communication regarding a particular condition of the patient and the caregiver, always this kind of communication was being affected strongly by three factors that were related to the condition of patient, the nurse, and the organization. In this theme, the three categories which emerged affect communicative performance of nurses were: Patient as the center of communication, nurse as a human factor, and organizational structures [Table 1]. These categories explain the underlying psychosocial and cultural factors influencing nurse–patient communication in oncology care environment.

Table 1 Categories and sub-categories in theme of three-factor effects

DISCUSSION

This study aims to explore the factors affecting the communication between patients with cancer and nurses. This study indicates that the triangle of patient, nurse, and organization can play a decisive role in the effectiveness of this communication. Problems related to these three factors have been stated in various studies.[14510122122]

Our participants explain that the impacts of the disease on the body, mind, and social life bring difficulties for them. In fact, paying comprehensive attention to these problems by nurses would facilitate communication process. The result of McCabe's study showed that considering the needs and problems of patients is a fundamental key in patient-centered communication.[5] The findings indicated the complexity of communication in end-stage patients. Perhaps, so the literature indicates, in this stage of cancer, patients are faced with unpleasant feelings and thoughts of death, and focus of health care providers must be shifted to the relief of emotional distress.[9212324] Moreover, our results showed that the appearance changes resulting from the disease and its treatment lead to weakening the patient's mood, which make it difficult to communicate with them. Understanding these changes and preparation of patient and family for dealing with these changes could reduce the severity of the patient's emotional distress. In patients with cancer, return to previous life is a dream, but when they realize that this would not happen, they are depressed. This situation could disrupt interactions with caregivers.[9]

Characteristics of the patients seemed to be an important influential factor on the communication, and the results of the present research showed that information-seeking differed from patient to patient depending on their educational level and the disease stage and patients with different conditions in terms of education level and stage of the disease demand different information and nurses can provide appropriate information consistent with the patient preferences and perception to gain the trust. Owen and Jeffrey pointed out that the need and demand for information differs in patients and depends on the patient's understanding of the issues and of his/her health literacy.[9] Fakhr- Movahedi et al. showed that information provision to patient influences on the nurse-patient communication and leads to building confidence in patients.[4]

In our study, more female patients mentioned different emotional needs than male patients. Moreover, the need for emotional support was more expressed by young females. The study of Wessels et al. also showed that among the factors related to patient, gender is the most influential factor on patients’ preferences.[25] Studies showed that females more than males prefer to receive psychosocial support during communication.[262728] This is not restricted to only patients, but family members are also affected by the disease. The need to support family members especially increases in the end stages of the disease, and if the family members were not supported in this situation, negative psychological reactions of relatives such as stress, tension, and worry will be transferred to the patient. This finding is not consistent with results of Fakhr-Movahedi et al., to be precise; they mentioned that presence of family members in the wards prevents nurse-patient communication.[4] Perhaps, this difference is related to the setting of their study, which was restricted to medical-surgical wards, where emotional support to patients was not as important as it is in oncology wards. In contrast, Park and Song found that for nurses, the absence of a family member as caregiver is the most important barrier in communication with patient.[29]

The other characteristic influencing in our results was language as the difference in language played a deterrent role in communication. A number of literatures,[142930] support our findings. In addition, gender differences between patient and nurse prevents friendly relationship, which was expressed mostly by female nurses and male patients participating in the research. In studies, patients’ preference for receiving care from a nurse of the same gender was referred as a cultural issue.[14] From the perspective of the people and health system managers, gender differences between patient and care providers is an important cultural challenge in Iran because it's a custom in Iran that nurses are prohibited from touching or gazing at patients of the opposite sex,[1] and the government has approved a plan to fit sex of health care providers with patients in 1998, but the shortage of nurses, especially male nurses has prevented its implementation.[31] Although in the current study, it was found that unmarried female nurses try to limit conversation with young male patients in interactions with them, other studies have not mentioned about this finding that we found in religious background of Iran as a Muslim country.

Professional and psychological characteristics of the nurses were other influential factors on the nurse-patient communication. According to our findings, the lack holistic perspective among nurses inclined them towards doing physician orders and physical care. Biomedical perspective in nurses obstructs emotional support for the patient and holistic care in clinical situations. This perspective was reflected in more attention of nurses to the technical aspects of the caring and meeting physical needs of patients. Study of Zamanzadeh et al. showed that patients with cancer and their nurses perceive physical aspects of care more valuable than other aspects.[32] Sivesind et al. study also indicated that nurses have less self-confidence in resolving non-physical problems and responding to emotional needs of patients.[33] These results show that nurses have not yet moved toward a holistic view in practice because a holistic nurse will be sensitive to the patient's whole spectrum of needs.[34] Papathanasiou et al. mentioned that ineffective communication through health systems is mostly derived from the biomedical view that has a negative effect on nursing care provision. This problem is rooted in the fact that the majority of nurses were graduated from educational systems, which focus only on practical skills.[35]

In addition, our study showed that nurses who have communication skills and knowledge gain the trust of patients in communication process. Systematic review of Rchaidia et al. indicated according to the patients perception that good nurses are characterized by professional and trained skills, specific nursing and non-nursing knowledge, and support provision.[36] Such nurses increase confidence, hope, comfort, and safety in their patients.[3637]

For the nurses participating in the current study, psychological pressure of caring of patients who are suffering from cancer was perceived as a factor influencing on the nurse-patient communication. They mentioned the sense of vulnerability as an effective factor on communication that could be understood through a long-term and friendly relationship with patient. Owen and Jeffrey believed that in long-term care of patients with cancer, nurses who share to patients’ distress in a close emotional connection with them, resulting in the emotional involvement of nurses that is harmful for them.[9] Rassouli et al. showed that fatigue in nurses working in oncology units is more related to emotional factors.[38] Aycock and Boyle define this phenomenon as compassion fatigue in oncology.[39] In addition, Anselm et al. claim that under such psychological tension, caregivers are unable to communicate effectively.[40] According to the experiences of nurses participating in the study, traumatic nature of work in oncology is related to death of patients that occurs frequently. Other studies referred to the fear of death in oncology and its impact on communication with patient.[91012]

Our research showed that in organizational dimension, factors such as time, workload, and imbalance between these two minimizes communication with patients. Furthermore, Maguire et al. noted that crowded conditions increase pressure for caregivers and waiting time for patients. In such situations, nurses do not have enough time to discover concerns of patients.[41] This finding is consistent with other studies that showed lack of time, heavy workload, work in extra shifts, and fatigue in nurses hindered nurse–patient communication.[442] In contrast, the study of Chan et al. showed that nurses with integrating communication within the routines that they tend to do, in practice prove that not only extra time is not needed to communicate with the patients but also good communication is possible without wasting their time.[43]

According to the present research, imposed caring duties in task-oriented organizational context reduce the communication with patients. Nurses participating in the study believe that if their managers meet the need of nurses, request them to do their all roles and monitor their work, all needs of the patients will be attended by the nurses. Other studies have showed that task-oriented approach results in regarding of many of the needs and problems of patients during communication.[15] Our findings demonstrated that nurses’ tendency to perform dependent tasks, the shadow of bio-medical paradigm over care, and physician-centered system hindered patient-centered communication. Study results indicated that nurses often focus on the physicians orders instead of the patient's needs and problems,[413] and causes the patients to feel that the nurses’ duties and physician orders have more importance than patients.[5] Our findings indicated that the lack of monitoring on communication processes by nursing managers influences on the nurse-patient communication. In a task-oriented structure, in which nursing managers do not emphasize on the communication with patient, reduction of communication is expectable.[510] In order to confirm this issue, Anoosheh et al. found that lack of nursing manager appreciation of communication behaviors of nurses decreases communication with patient.[1]

Systematic review of Gysels et al. indicated the moderate effectiveness of training courses in increasing the communication skills and facilitator attitudes. In addition, it emphasizes that the effectiveness of courses is relevant to long-term courses, integrating theory, and practical exercises and getting feedback from colleagues.[4445] Our research suggested that nurses perceived the type and the quality of training courses as insufficient in improving their communication skills. They requested the kind of education, which is consistent with their communications needs in oncology. Study of Wilkinson et al. showed that communication skill training for nurses can change communication skills and the level of confidence in them to communicate with patients.[10]

CONCLUSION

Understanding the factors influencing the communication could be the first step to solve communication problems. In fact, it can be said that a satisfactory communication is impossible without sufficient and comprehensive understanding of the views of nurses and patients. In the present research, in the context of nurse-patient communication, routine and task-oriented approach reduced quality and quantity of care. Changes in the culture of the nursing care systems are essential in order for the patients to feel that their individuality is more regarded than the nurses’ works. Nurses must feel that they receive proper training for care and communication with patients. These trainings should promote nurses’ perception of their various roles for providing support to the patients with cancer. Managers must support nurses emotionally considering nurses’ personal and professional problems. Furthermore, they must prevent burnout by balancing the workload and staffing. This research was conducted based on the experiences of Iranian patients with cancer, their family members and the nurses, and according to a few studies in this area, it is necessary that factors influencing nurse-patient communication in other life-threatening chronic conditions has to be researched.